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FORM 941AF-ME

Maine Revenue Services

Nonresident Member Afﬁ davit and Agreement

to Comply with Maine Income Tax

1. I am a nonresident member of a pass-through entity with Maine-source income.

___________________________________________________________

Member’s name:

_________________________________________________________

2. Member’s address:

: __________________________

3. Member’s social security number or taxpayer identiﬁ cation number

4. The pass-through entity for which this afﬁ davit and agreement applies:

____________________________________________________

Pass-through entity’s name:

__________________________________________________

Pass-through entity’s address:

Pass-through entity’s taxpayer identiﬁ cation number: ___________________________________________

5. I agree that I am subject to the personal jurisdiction of the State of Maine and its agencies and courts for the purpose

of determining and collecting Maine income taxes due, including estimated taxes, together with any related

interest and penalties.

6. I agree to timely ﬁ le appropriate returns and make payment of all Maine income taxes, including estimated payments,

required by law. If the entity completing this afﬁ davit (member listed in item 1) is an upper-tier pass-through entity, the

entity agrees to withhold Maine income tax from its members in accordance with 36 M.R.S. § 5250-B and MRS

Rule 803.06 or to obtain exemptions from the withholding requirement in accordance with MRS Rule 803.06 and the

instructions for Form 941P-ME.

7. This agreement is binding upon my heirs, representatives, assigns, successors, executors and administrators.

8. I understand and agree that Maine Revenue Services may revoke the pass-through entity withholding exemption at

any time it determines that I am not abiding by the terms of this agreement.

9. I authorize Maine Revenue Services to disclose to the entity named in paragraph 4 of any failure on my part to timely

ﬁ le appropriate returns and/or make payment of all Maine income taxes required by law.

Under penalties of perjury, I declare that I have examined this form and statements and to the best of my knowledge

and belief they are true, correct and complete.

________________________________________________________________________________

Signature of member

Date

________________________________________________________________________

Printed name

This afﬁ davit must be held by the pass-through entity. It is not necessary to submit a new afﬁ davit each year. The afﬁ davit

will remain in force continuously as long as the member retains an ownership interest in the pass-through entity and

it is not revoked. The afﬁ davit is automatically revoked if for any reason the pass-through entity does not include the

nonresident member on the Schedule 3P submitted with the Maine annual pass-through entity return (Form 941P-ME). A

revoked afﬁ davit must be retained by the pass-through entity for at least three years after the year in which it is revoked.

Revised: December 2016

Form 941af-Me - Nonresident Member Affidavit And Agreement To Comply With Maine Income Tax - 2016